CPT 90791 + ICD-10 F41.1: Generalized Anxiety Disorder
Psychiatric diagnostic evaluation billed with Generalized Anxiety Disorder — documentation requirements, denial reasons, modifiers, and reimbursement context.
CPT Code
90791
Psychiatric diagnostic evaluation
ICD-10 Code
F41.1
Generalized Anxiety Disorder
Compatibility Notes
Used for the initial psychiatric or psychological evaluation of a patient presenting with generalized anxiety. 90791 is appropriate for the intake session where the diagnosis is established. Most payers allow one 90791 per year per provider without prior authorization. Document the comprehensive evaluation — this is not a therapy session.
Documentation Required
- ✓Comprehensive face-to-face evaluation with psychiatric history
- ✓GAD DSM-5 criteria assessed and documented
- ✓GAD-7 or equivalent administered at intake
- ✓Medical history, medications, and substance use screened
- ✓Risk assessment (suicidal ideation, self-harm)
- ✓Diagnostic impression and treatment recommendations
Common Denial Reasons
- ✗90791 billed more than once per year by same provider
- ✗Evaluation notes read like a therapy session note rather than a diagnostic evaluation
- ✗Diagnosis already established elsewhere with no basis for a new evaluation
Applicable Modifiers
Reimbursement Notes
OON UCR $175–$350. The intake evaluation is one of the highest-reimbursed sessions; bill 90791 for every new patient evaluation rather than 90837.
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